The reliability of axis II of DSM-III

Interdiagnostician Reliability of the DSM-5 Section II and Section III Alternative Model Criteria for Borderline Personality Disorder

This study examined the interdiagnostician reliability and potential gender bias of the DSM-IV/DSM-5 Section II and DSM-5 Alternative Model definitions of borderline personality disorder. A national sample of 123 mental health professionals provided diagnostic judgments on 12 case vignettes selected to represent a range of personality pathology. Two versions of each case were included, one identified as male and the other as female, but which were otherwise identical. Analyses examined the intraclass correlation between clinicians and also examined rates of diagnostic assignments as a function of case gender. Reliability of diagnosis of borderline personality did not differ across the two diagnostic approaches, and concordance of diagnoses across the two systems was significant. The dimensional components of the DSM-5 Alternative Model demonstrated significantly more diagnostic reliability than the DSM-IV categorical diagnoses. The DSM-5 Alternative Model conceptualization of borderline personality can be diagnosed with comparable or greater reliability than the extant DSM-IV definition.

Mistrustful and Misunderstood: A Review of Paranoid Personality Disorder

PURPOSE OF REVIEW

Paranoid Personality Disorder (PPD) has historically been neglected by science out of proportion to its prevalence or its association with negative clinical outcomes. This review provides an update on what is known about PPD regarding its prevalence, demographics, comorbidity, biological mechanism, risk factors, and relationship to psychotic disorders.

RECENT FINDINGS

PPD has long been the subject of a rich and prescient theoretical literature which has provided a surprisingly coherent account of the psychological mechanism of non-delusional paranoia. Available data indicate that PPD has a close relationship with childhood trauma and social stress. Descriptive data on a sample of 115 individuals with Paranoid Personality Disorder is examined in comparison with a group of individuals with Borderline Personality Disorder. The descriptive data largely confirm previously identified relationships between Paranoid Personality Disorder and childhood trauma, violence, and race. We identify important similarities to and differences from Borderline Personality Disorder.

SUMMARY

PPD continues to be an important construct in the clinic and the laboratory. Available data lead to a reconsideration of the disorder as more closely related to trauma than to schizophrenia.

Psychopathy and the DSM

Psychopathy is one of the more well-established personality disorders. However, its relationship with the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) has been controversial. The purpose of this article is to trace and discuss the history of this relationship from the very first edition of the DSM to the current fifth edition. Emphasized in particular is the problematic relationship of DSM antisocial personality disorder with the diagnosis of psychopathy by Cleckley (1941, 1976) and the Psychopathy Checklist- Revised (Hare, 2003), as well as with the more recently developed models of psychopathy by Lilienfeld and Widows (2005), Lynam et al. (2011), and Patrick, Fowles, and Krueger (2009).

The relationship between borderline personality disorder and bipolar disorder

It is clinically important to recognize both bipolar disorder and borderline personality disorder (BPD) in patients seeking treatment for depression, and it is important to distinguish between the two. Research considering whether BPD should be considered part of a bipolar spectrum reaches differing conclusions. We reviewed the most studied question on the relationship between BPD and bipolar disorder: their diagnostic concordance. Across studies, approximately 10% of patients with BPD had bipolar I disorder and another 10% had bipolar II disorder. Likewise, approximately 20% of bipolar II patients were diagnosed with BPD, though only 10% of bipolar I patients were diagnosed with BPD. While the comorbidity rates are substantial, each disorder is nontheless diagnosed in the absence of the other in the vast majority of cases (80% to 90%). In studies examining personality disorders broadly, other personality disorders were more commonly diagnosed in bipolar patients than was BPD. Likewise, the converse is also true: other axis I disorders such as major depression, substance abuse, and post-traumatic stress disorder are also more commonly diagnosed in patients with BPD than is bipolar disorder. These findings challenge the notion that BPD is part of the bipolar spectrum.

The impact of a diagnosis of personality disorder on service usage in an adult Community Mental Health Team

PURPOSE

Patients with a diagnosis of personality disorder (PD) have multiple and diverse needs. It has been noted that individuals with personality disorder are high users of health care resources, especially psychiatric services, ambulance services and emergency departments. In addition PD has been shown to be a significant predictor of disability and mental health consultations independent of Axis I disorders and physical conditions. This study aimed to compare the patterns of service usage, clinical ratings of symptoms and functioning, as well as demographic and clinically relevant historical variables between a group of patients with PD and a random sample of all other patients registered with a South London Community Mental Health Team.

METHODS

A case–control design was used to examine service usage patterns over a one-year period for 73 cases and 96 controls. Diagnoses were established by clinician discussion. Clinical outcomes were measured with Health of the Nation Outcome Scales and Global Assessment of Functioning, while service use was recorded using ten variables obtained from case note review.

RESULTS

People with a diagnosis of PD were more often white and had a history of abuse, particularly childhood emotional abuse. They were higher users of some aspects of the service as compared to controls, and had significantly higher severity of symptoms and poorer functioning on clinician-rated measures.

CONCLUSION

This study confirms previous findings that people with PD have more severe symptomatology and greater degrees of functional impairment when compared to those without. Community clinicians should routinely screen attenders to predict likely difficulties that might arise and to make provision for these difficulties in the treatment and management of clients.

Clinical utility of Standardised Assessment of Personality - Abbreviated Scale (SAPAS) among patients with first episode depression

BACKGROUND

Personality disorder frequently co-occurs with depression and seems to be associated with a poorer outcome of treatment and increased risk for recurrences. However, the diagnosing of personality disorder can be lengthy and requires some training. Therefore, a brief screening interview for comorbid personality disorder among patients suffering from depression would be of clinical use.

METHOD

The present study aimed to assess the utility of the Standardised Assessment of Personality - Abbreviated Scale (SAPAS) as a screen for personality disorder in a population of patients recently diagnosed with first episode depression. A total number of 394 patients with an ICD-10 diagnosis of a single depressive episode were sampled consecutively via the Danish Psychiatric Central Research Register during a 2years inclusion period and assessed by the screening interview and, subsequently, by the Structured Clinical Interview for DSM-IV Personality Disorders.

RESULTS

We found, that a cut-off of 3 on the screen correctly identified the presence of comorbid personality disorder in 73.1% of the patients. The sensitivity and specificity were 0.80 and 0.70, respectively.

LIMITATIONS

The findings cannot be generalized to patients outside hospital settings.

CONCLUSION

The study provides evidence for the clinical utility of SAPAS as a screening interview for comorbid personality disorder in a population of patients with a primary diagnosis of depression.

Lessons learned from the clinical reappraisal study of the Composite International Diagnostic Interview with Latinos

Given recent adaptations of the World Health Organization's World Mental Health Composite International Diagnostic Interview (WMH-CIDI), new methodological studies are needed to evaluate the concordance of CIDI diagnoses with clinical diagnostic interviews. This paper summarizes lessons learned from a clinical reappraisal study done with US Latinos. We compare CIDI diagnoses with independent clinical diagnosis using the World Mental Health Structured Clinical Interview for DSM-IV (WMH-SCID 2000). Three sub-samples stratified by diagnostic status (CIDI positive, CIDI negative, or CIDI sub-threshold for a disorder) based on nine disorders were randomly selected for a telephone re-interview using the SCID. We calculated sensitivity, specificity, and weight-adjusted Cohen's kappa. Weighted 12 month prevalence estimates of the SCID are slightly higher than those of the CIDI for generalized anxiety disorder, alcohol abuse/dependence, and drug abuse/dependence. For Latinos, CIDI-SCID concordance at the aggregate disorder level is comparable, albeit lower, to other published reports. The CIDI does very well identifying negative cases and classifying disorders at the aggregate level. Good concordance was also found for major depressive episode and panic disorder. Yet, our data suggests that the CIDI presents problems for assessing post-traumatic stress disorder (PTSD) and generalized anxiety disorder (GAD). Recommendations on how to improve future versions of the CIDI for Latinos are offered.

Person Theories: Their Temporal Stability and Relation to Intertrait Inferences

This article tests whether individual differences in inferring one trait from another (intertrait inferences) can be linked to lay beliefs about the malleability of personality (person theories). It finds that holding the belief that personality is malleable (incremental theory) rather than fixed (entity theory) at the time of inferences is associated with less extreme inferences involving semantically related (but not unrelated) traits. Although person theories have been assumed to be stable over time, existing short-term test—retest coefficients do not capture their instability over a longer period. These results can illuminate interrater discrepancies in assessments of personality pathology and job performance, enrich understanding of such phenomena as stereotyping and impression formation, refine the interpretation of past research involving person theories, and inform research planning.

Clinical utility of dimensional models for personality pathology

Clinical utility is defined as the extent to which the DSM assists clinical decision makers in fulfilling the various clinical functions of a psychiatric classification system. Distinction is made between elements of diagnostic validity that are more or less conditional to utility (i.e., coverage, and consistency with etiology and prognosis) and components of clinical utility in the narrow sense of the term (i.e., user acceptability and accuracy, communication, reliability, subtlety, and clinical decision making). Clinical utility is often considered the driving force behind the respective revisions of the DSM system, yet it has been difficult if not impossible to obtain reasonable levels of clinical utility within categorical classifications of personality disorders. This paper presents evidence that a dimensional diagnostic system will substantially improve clinical utility, especially with respect to coverage, reliability, subtlety, and clinical decision making. In addition, some evidence suggests that the purely dimensional models outperform the so-called hybrid models (i.e., dimensional profiling of categories) with respect to coverage, consistency with etiology, subtlety, and clinical decision making. Several research options that might inform future revisions, including the choice or development of a dimensional classification, are suggested.

Evidence-based assessment of personality disorders

The purpose of this article is to provide a foundation for the development of evidence-based guidelines for the assessment of personality disorders, focusing in particular on integrated assessment strategies. The general strategy recommended herein is to first administer a self-report inventory to alert oneself to the potential presence of particular maladaptive personality traits followed by a semistructured interview to verify their presence. This strategy is guided by the existing research that suggests particular strengths of self-report inventories and semistructured interviews relative to unstructured clinical interviews. However, the authors also consider research that suggests that further improvements to the existing instruments can be made. The authors emphasize, in particular, a consideration of age of onset, distortions in self-perception and presentation, gender bias, culture and ethnicity, and personality change.

Using the SWAP-200 in a personality-disordered forensic population: is it valid, reliable and useful?

BACKGROUND

Treatment and risk management of forensic patients relies heavily on diagnosing psychopathology, yet the reliability of clinical diagnoses of personality disorder has been found to be only fair to low. Structured instruments for the global assessment of personality disorder are infrequently used in clinical assessments possibly due to their limited validity and clinical utility.

AIMS/METHODS

The Shedler-Westen Assessment Procedure-200 (SWAP-200) was developed in an effort to address these limitations. Although good reliability and validity in relation to clinicians' diagnosis of personality disorder has been reported, to date the validity of this instrument has not been assessed in relation to other standardized instruments or in a personality-disordered, forensic population. This study aims to establish the reliability and validity of the SWAP-200 against other diagnostic instruments and measures of interpersonal functioning in a personality disordered forensic population.

RESULTS

This paper reports the results of 30 subjects from a high secure hospital in the UK who were assessed with the SWAP-200, the Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II), the Adult Attachment Interview (AAI) and the Chart of Interpersonal Reactions in Closed Living Environments (CIRCLE). Preliminary results suggest that the SWAP-200 is a reliable instrument for the diagnosis of personality disorder in forensic patients.

CONCLUSIONS

Although the small sample size allows only preliminary conclusions about the validity of this instrument, early results show a reduction of the diagnosis of comorbidity compared with the SCID-II, together with an increased number of expected associations between independent measures of interpersonal functioning and categories of personality disorder.

Concordance of DSM-IV Axis I and II diagnoses by personal and informant's interview

The validity and reliability of using psychological autopsies to diagnose a psychiatric disorder is a critical issue. Therefore, interrater and test-retest reliability of the Structured Clinical Interview for DSM-IV Axis I and Personality Disorders and the usefulness of these instruments for the psychological autopsy method were investigated. Diagnoses by informant's interview were compared with diagnoses generated by a personal interview of 35 persons. Interrater reliability and test-retest reliability were assessed in 33 and 29 persons, respectively. Chi-square analysis, kappa and intraclass correlation coefficients, and Kendall's tau were used to determine agreement of diagnoses. Kappa coefficients were above 0.84 for substance-related disorders, mood disorders, and anxiety and adjustment disorders, and above 0.65 for Axis II disorders for interrater and test-retest reliability. Agreement by personal and relative's interview generated kappa coefficients above 0.79 for most Axis I and above 0.65 for most personality disorder diagnoses; Kendall's tau for dimensional individual personality disorder scores ranged from 0.22 to 0.72. Despite of a small number of psychiatric disorders in the selected population, the present results provide support for the validity of most diagnoses obtained through the best-estimate method using the Structured Clinical Interview for DSM-IV Axis I and Personality Disorders. This instrument can be recommended as a tool for the psychological autopsy procedure in post-mortem research.

Screening for personality disorder: a comparison of personality disorder assessment by patient and informants

The Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II Version 2.0) is becoming the most favoured instrument to measure personality disorder but takes up to an hour to complete. The Standardized Assessment of Personality (SAP), an informant-based measure, takes 10 to 15 minutes to complete. Both instruments have been validated independently. This study aimed to determine whether the SAP is a suitable screening instrument for personality disorder as measured by the SCID-II. Fifty-seven psychiatric patients were assessed for personality disorder using both the SAP and the SCID-II. The SAP assessments were conducted blind to the results of the SCID-II assessments. Agreement between the two instruments in this population was low (kappa = 0.3). The level of agreement differed between personality disorder categories, ranging from kappa = 0.4 (antisocial) to 0.1 (narcissistic). In this population of patients, the SAP proved to be a poor screen for the SCID-II. The study highlights the discrepancy between informant and self-report assessments for personality disorder.

Standardised Assessment of Personality - Abbreviated Scale (SAPAS): preliminary validation of a brief screen for personality disorder

BACKGROUND

There is a need for a brief and simple screen for personality disorders that can be used in routine psychiatric assessments.

AIMS

To test the concurrent validity and test-retest reliability of a brief screen for personality disorder.

METHOD

Sixty psychiatric patients were administered a brief screening interview for personality disorder. On the same day, they were interviewed with an established assessment for DSM-IV personality disorder. Three weeks later, the brief screening interview was repeated in order to examine test-retest reliability.

RESULTS

A score of 3 on the screening interview correctly identified the presence of DSM-IV personality disorder in 90% of participants. The sensitivity and specificity were were 0.94 and and 0.85 respectively.

CONCLUSIONS

The study provides preliminary evidence of the usefulness of the screen in routine clinical settings.

Diagnosing antisocial personality disorder among substance abusers: the scid versus the MCMI-II

There is much controversy among social scientists and clinicians over the proper measurement of antisocial personality disorder (ASPD). The degree to which various diagnostic measures differ in their assessment of ASPD among substance abusers is not known. This study assessed the degree of agreement between a semistructured clinical interview and a self-report inventory on a diagnosis of ASPD among substance abusers. The Structured Clinical Interview for DSM-III-R (SCID-II), a clinically generated instrument, and the Millon Clinical Multiaxial Inventory (MCMI-II), a self-report inventory, were administered to 275 clients randomly assigned to two therapeutic communities (TCs). Based on the limited existing literature, it was hypothesized that there would be minimal agreement between the diagnosis of ASPD by the two scales. This hypothesis was supported. The kappa statistic indicated low agreement between the scales (kappa = 0.27), with the MCMI-II diagnosing ASPD more often than the SCID-II. The low agreement on a diagnosis of ASPD may be due to the different types of information collected by the two scales. The SCID-II emphasizes observable behavioral criteria, while the MCMI-II emphasizes pathological personality traits. The focus of the MCMI-II on pathological personality traits may more accurately diagnose ASPD in substance-abusing populations in which the majority of the clients have extensive criminal histories. Definite conclusions regarding the proper measurement of ASPD in substance-abusing samples is difficult without additional empirical evidence.

A comparison of the Composite International Diagnostic Interview (CIDI-Auto) with clinical assessment in diagnosing mood and anxiety disorders

OBJECTIVE

Increasingly, epidemiological studies are employing computerized and highly standardized interviews, such as the Composite International Diagnostic Interview (CIDI-Auto), to assess the prevalence of psychiatric illness. Recent studies conducted in specialist units have reported poor agreement between experienced clinicians' and CIDI-Auto diagnoses. In this study we investigated the concordance rate between clinicians and the CIDI-Auto for the diagnosis of six anxiety disorders and two mood disorders, whereby the CIDI-Auto was treated as the 'gold standard'.

METHOD

Subjects were 262 patients who were assessed by a clinical psychologist or psychiatrist and completed the CIDI-Auto at a tertiary referral unit for anxiety and mood disorders. Agreement between the clinicians' diagnoses and the diagnoses generated by the CIDI-Auto according to both DSM-IV and ICD-10 codes, were examined by kappa statistics. Sensitivity and specificity values were also calculated.

RESULTS

Agreement between clinicians and the CIDI-Auto (DSM-IV) ranged from poor for social phobia and posttraumatic stress disorder (kappa < 0.30) to moderate for obsessive- compulsive disorder (OCD; kappa = 0.52). Agreement between clinicians and the CIDI-Auto (ICD-10) ranged from poor for major depressive episode (kappa = 0.25) to moderate for OCD (kappa = 0.57). With the CIDI diagnosis treated as the gold standard, clinicians' diagnoses showed low sensitivity (kappa < 0.70) for all the disorders except for OCD (for ICD-10), but high specificity (kappa > 0.70) for all the disorders.

CONCLUSION

Poor agreements between experienced clinicians and the CIDI-Auto were reported for anxiety and mood disorders in the current study. A major implication is that if diagnosis alone directed treatment, then patients could receive different treatments, depending on whether the computer, or a clinician, made the diagnosis.

Issues in the assessment and conceptualization of personality disorders

This article reviews several current issues associated with the definition and assessment of personality disorders (PDs) as defined in the third and fourth editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Specifically reviewed are issues associated with classification, PD conceptualizations, and the assessment of these disorders. DSM PD categories are also reviewed in terms of their psychometric properties. A review of the PD assessment literature suggests that DSM conceptualizations and definitions of PDs are problematic at both conceptual and quantitative levels. This article concludes with suggestions for possible alternative approaches to and modifications of DSM PD assessment.

Passive-aggressive personality disorder: the demise of a syndrome

This article presents an explanation and critique of the rationale for dropping passive-aggressive personality disorder (PAPD) from DSM-IV. The clinical and research literature on PAPD is reviewed along with the historical changes in definition, diagnostic criteria, and usage. PAPD can be reliably diagnosed, is fairly prevalent, and has good internal consistency. Because PAPD is no less valid than other personality disorders, and describes clinical phenomena that are unique among personality disorders, we recommend the reinstatement of PAPD in the official diagnostic nomenclature.

Recognizing comorbid personality disorder can help manage and treat the "untreatable"

Personality disorder is surprisingly prevalent. Clinical syndromes accompanied by personality disorder tend to be more severe, more treatment resistant, and more likely to recur than their counterparts. Learning to recognize personality disorder can enhance the efficacy of the clinician's management style and his or her ability to make appropriate plans for long-term psychotherapy. To assist diagnosis of personality disorder according to the DSM-IV, the authors present interpersonal descriptions and necessary and exclusionary conditions.

Evolution of personality disorder diagnosis in the Diagnostic and Statistical Manual of Mental Disorders

This article reviews the history and evolution of the diagnosis of personality disorders according to the Diagnostic and Statistical Manual of Mental Disorders (DSM) from its first edition in 1952 through its fourth edition in 1994. The article also traces the earliest origins of personality disorders (e.g., Hippocrates) through the modern foundational works of Pritchard, Schneider, and Horney. Analysis of the changes across the editions of the DSM suggest slow but steady progress in the clarification and classification of personality disorders, although formidable challenges remain. A call for future research as to reliability and validity of personality disorders is made, and suggestions for research are offered.

Reliability of self-reported antisocial personality disorder symptoms among substance abusers

It is estimated that from 20 to 60% of substance abusers meet criteria for Antisocial Personality Disorder (APD). An accurate and reliable diagnosis is important because persons meeting criteria for APD, by the nature of their disorder, are less likely to change behaviors and more likely to relapse to both substance abuse and high risk behaviors. To understand more about the reliability of the disorder and symptoms of APD, the Diagnostic Interview Schedule Version III-R (DIS) was administered to 453 substance abusers ascertained from treatment programs and from the general population (St Louis Epidemiological Catchment Area (ECA) follow-up study). Estimates of the 1 week, test-retest reliability for the childhood conduct disorder criterion, the adult antisocial behavior criterion, and APD diagnosis fell in the good agreement range, as measured by kappa. The internal consistency of these DIS symptoms was adequate to acceptable. Individual DIS criteria designed to measure childhood conduct disorder ranged from fair to good for most items; reliability was slightly higher for the adult antisocial behavior symptom items. Finally, self-reported 'liars' were no more unreliable in their reports of their behaviors than 'non-liars'.

Temporal stability of antisocial personality disorder: blind follow-up study at 8 years

The study objective was to examine the temporal stability of the antisocial personality disorder (ASPD) diagnosis based on whether specific antisocial symptoms were considered to be related to substance abuse. A total of 407 adults who were initially part of a family study of alcoholism and sociopathy were blindly reassessed an average of 8 years later, using the Home Environment and Lifetime Psychiatric Evaluation Record (HELPER) and basing diagnoses on the clinician's best final estimate using all sources of data. "Narrow" and "broad" ASPD diagnoses were made at both times based on whether individual symptoms were counted toward diagnosis if they occurred in the setting of significant substance abuse. kappa values varied from 0.31 to 0.68, with more restrictive methods of diagnosis being less stable. After deriving estimates of sensitivity and specificity of diagnosis, the probability of being a "case" could be assigned based on the reported number of conduct problems occurring before age 15 as a clinical covariate for diagnosis. We conclude that diagnosing ASPD without attempting to attribute the cause of individual symptoms to substance abuse results in substantially greater temporal stability. Using a broader definition, the diagnosis of ASPD is highly sensitive (P = .97) and specific (q = 0.93). These findings may allow more accurate diagnosis of ASPD in drug-abusing individuals.

Construct validity of the Beck Depression Inventory in a depressive population

This study investigates the construct validity of the Beck Depression Inventory (BDI) in a large population of DSM-III unipolar depressive inpatients. The BDI correlates weakly with the Hamilton scale and differentiates between minor, major and melancholic/psychotic unipolar depressive subgroups. Factor analysis of the BDI resulted in psychological/cognitive (BDIPSY) and somatic/vegetative (BDISOM) subscales. The BDISOM subscale displayed a narrower relationship with the depression construct, as evidenced by a better differential validity and by significant effects for the DST non-suppression response. The present findings generally lend support to the construct validity of the BDI in depressive populations.

Recent Developments in the Clinical Assessment of Personality Disorders

Each of the latest editions of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders has given special attention to the diagnosis of personality disorders. However, the assessment of personality disorders is among the most problematic and controversial of the mental disorders. The purpose of this paper is to provide an overview of the major issues in the assessment of personality disorders, and to provide suggestions for their resolution. Issues that are covered include the differentiation of personality disorders from other mental disorders, from other personality disorders, and from normal personality functioning. We also discuss alternative instruments for the assessment of personality disorders, focusing in particular on various self-report inventories and semistructured interviews.

Prevalence of personality disorders in two geropsychiatric inpatient units

One hundred males from a Veterans Affairs geropsychiatric inpatient ward, and 100 females from a geropsychiatric inpatient ward of a private hospital completed the Structured Interview for Disorders of Personality-Revised (SIDP-R). Chart reviews provided information including age, years of education, marital status, race, as well as Axis I and Axis II psychiatric diagnoses. Data from a young adult sample, drawn from an initial SIDP-R validation study, were used for comparison. Results indicate a 56.5% rate of personality disorders (PD) for older patients. Significantly more elderly men than elderly women were diagnosed with PD by psychiatric evaluation, and elderly men were also more likely to be diagnosed with paranoid, avoidant, and multiple PD using the SIDP-R. Psychiatrists gave far fewer Axis II diagnoses than were yielded by the SIDP-R, particularly with females. There were no significant differences in total PD rates between aged and young subjects, but older adults with PD were diagnosed less frequently with multiple PD. Older adults were also less likely to be diagnosed with the "Dramatic" cluster PD, and more likely to be diagnosed with the "Odd" cluster PD. The level of depression was related to both clinical and SIDP-R diagnoses.

SCID II interviews and the SCID Screen questionnaire as diagnostic tools for personality disorders in DSM-III-R

A modified version of the SCID Screen questionnaire covering 103 criteria by means of 124 questions was compared with SCID II interviews in 69 psychiatric patients. The correlation between the number of criteria fulfilled in the SCID II interviews or the questionnaires was 0.84. In the SCID interviews, 54% of the patients had a personality disorder. When the SCID Screen questionnaire was used, 73% had a personality disorder. When the cut-off level for diagnosis was adjusted, the frequency found by means of the SCID screen questionnaire or the interviews was roughly the same, 58% and 54%, respectively. The overall kappa for agreement between the SCID II interviews and questionnaire with adjusted cut-off was 0.78.

"Patterns of comorbidity" among DSM-III-R and ICD-10 personality disorders as observed with a new inventory for the assessment of personality disorders

Although DSM-III-R and ICD-10 suggest the assignment of multiple personality diagnoses, a high degree of overlap may be an indicator of insufficiently distinct and too inclusive types of personality. We studied this problem with a new inventory in an unselected clinical sample. The Aachen List of Items for the Registration of Personality Disorders (AMPS) integrates the different types of disordered personality according to DSM-III-R, ICD-10, and four subaffective categories, which largely follow the typologies of Kraepelin, K. Schneider, and Kretschmer. The prevalence rate of each personality disorder was calculated in a consecutive group of 231 patients. Patterns of comorbidity were computed using odds ratios. More than one personality disorder was found in 41% according to DSM-III-R. ICD-10 showed a significantly higher degree of overlap. Interesting comorbidity patterns are discussed in comparison with several North American studies. Results indicate that clear-cut categorical personality diagnoses are not likely to be set up.

Empirical determination of thresholds for case identification: validation of the Personality Diagnostic Questionnaire-Revised

The Personality Diagnostic Questionnaire-Revised (PDQ-R) was sent to first-degree relatives of major psychotic patients for identification of DSM-III-R personality disorders (PDs). Responses to the PDQ-R were interpreted both literally and empirically, and compared with the Structured Interview for DSM-III PDs (SIDP) as the standard. For literal interpretation, symptoms reported were counted directly for case identification using fixed DSM-III-R thresholds. The empirical approach adjusted the threshold for case identification to maximize concordance with the SIDP. Comparison of the two methods showed that using empirically determined thresholds in some scales gives better concordance with the SIDP. For the dependent and histrionic PD scales, the improvements were statistically significant. The area under the receiver operating characteristic (ROC) curve was computed for each PDQ-R scale to summarize its discriminatory capability across all thresholds. Areas under the ROC curve indicated that the schizoid, schizotypal, borderline, dependent, passive-aggressive, and histrionic PD scales in the PDQ-R have better discriminatory qualities than other PDQ-R scales.

The TRH-stimulation test in DSM-III personality disorder

The authors examined thyrotropin-releasing hormone (TRH) stimulation testing in the neuroendocrine evaluation of DSM-III major depressive disorder in 26 consecutive medication-free, medically healthy patients meeting a primary DSM-III diagnosis of axis II personality disorder. Thyroid-stimulating hormone (TSH) responses to TRH challenge were not significantly different between patients with or without major depression at time of study, or between patients with or without a life history of major affective disorder. Further, TSH responses to TRH among 11 healthy male nonpsychiatric controls were not significantly different from those in patients with personality disorders. Comparison of those patients with blunted TSH responses (< 7.0 microU/ml) versus those without blunted response (< or = 7.0 microU/ml) also did not reveal a significant difference. In addition, the TSH response to TRH did not correlate with dimensional assessments of state or trait depression, anxiety, or with past history of suicide attempt or alcohol abuse. These data suggest that TRH stimulation testing has limited utility in the evaluation of major depression or other relevant affective states/traits in personality-disordered patients. Affective symptoms in personality-disordered patients do not seem to be associated with dysregulation of the hypothalamic-pituitary-thyroid axis.

Neuropsychological function in borderline personality disorder

To evaluate the possibility of an underlying dimension of organicity in borderline personality disorder (BPD), a carefully diagnosed group of borderline patients was assessed across a wide range of neuropsychological functions and then was compared to an age- and education-matched non-patient control group. The BPD group had significantly lower Verbal, Performance, and Full Scale IQ scores on the WAIS-R. The BPD group also was impaired significantly on motor skills, figural memory, complex visuomotor integration, social or interpersonal intelligence, and on a measure of susceptibility to interference. This pattern of deficits localized to the fronto-temporal regions and became more pronounced when a subgroup analysis was performed. This study suggests that subtle organic factors may be operative in some, but not all, BPD patients.

An investigation into the internal structure of DSM-III antisocial personality disorder

The present study examined the DSM-III antisocial personality disorder by examining endorsements of each of the DSM-III criteria to obtain various indices, including interrater reliability, sensitivity, specificity, positive and negative predictive power, alpha levels, and item (criterion)-total correlations. 112 psychiatric inpatients were rated on the Structured Interview for DSM-III Personality. 11 patients were accorded a diagnosis of antisocial personality disorder, 65 had other forms of personality disorders, and 36 received no personality disorder diagnosis. The antisocial criteria successfully discriminated patients with antisocial personality disorder from those without the diagnosis. Strong interrater reliability and reasonable alpha levels were achieved. Although some criteria were successful in identifying patients with and without a diagnosis of antisocial personality disorder, the criteria were generally better at predicting the absence of antisocial personality disorder.

Reliability and validity of the Coolidge Axis II Inventory: a new inventory for the assessment of personality disorders

This group of studies describes the development of a 200 item, self-report, 4-point true-false inventory (Coolidge Axis II Inventory [CATI]) to assess personality disorders according to the criteria established in the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev. [DSM-III-R]; American Psychiatric Association, 1987). The 13 personality disorder scales of the CATI had a mean test-retest reliability of .90 and a median internal consistency (Cronbach's alpha) of .76. There was a 50% concordance rate with clinician's diagnosis for 24 personality disordered patients. The median concurrent validity (raw score sums) between the CATI and the Millon Clinical Multiaxial Inventory-II for the 13 personality disorder scales was .58. Preliminary studies also support the reliability and validity of Depression, Anxiety, and Brain Dysfunction scales.

The interrater reliability of a Dutch version of the Structured Clinical Interview for DSM-III-R Personality Disorders

This study presents data on the interrater reliability of a Dutch version of the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II). Seventy outpatients were interviewed before the start of their treatment by one rater, while a second rater observed. Both raters were instructed to make independent ratings and the second rater was not allowed to participate in the discussion. On criterion level, interrater reliabilities appear to be very good, with a few exceptions (most reliabilities are higher than 0.75). However, all 5 observation criteria had poor interrater reliabilities. Agreement on personality disorder, on the whole, was excellent (overall kappa = 0.80). The possible reasons why relatively lower reliabilities are found with some criteria are discussed. Finally, problems encountered during the interviews are addressed and possible adjustments of the SCID-II are suggested.

Interrater reliability of the Structured Clinical Interview for DSM-III-R, Axis II: schizophrenia spectrum and affective spectrum disorders

Three interviewers (second raters) blindly rated 15 audiotapes each of the Structured Clinical Interview for DSM-III-R, Axis II (SCID-II) administered to the first degree relatives of probands with either DSM-III-R schizophrenia, schizoaffective disorder, or bipolar disorder, for a total of 45 second ratings. Interrater reliability was determined using the intraclass correlation coefficient and ranged from 0.60 to 0.84. The previous studies of the reliability of structured interviews for diagnosing personality disorders are summarized and compared to the present findings. We conclude that the SCID-II can be reliably used to diagnose schizophrenia-spectrum and affective spectrum disorders in the first degree family members of probands with schizophrenic or bipolar affective disorders.

Adjustment reactions: a long-term prospective and retrospective follow-up of former patients in a crisis intervention ward

The results of a 5-year follow-up study of 76 patients in a crisis intervention ward who were suffering from an adjustment reaction (brief or prolonged depressive reaction) according to ICD-9 criteria indicate a rather favorable course and outcome using standardized instruments. Only 17% developed a chronic or severe course of primarily depressive symptoms and only 1 (2%) patient committed suicide after discharge, whereas 64% had a very favorable and 18% a favorable course and outcome. This result is reflected in a rather low use of psychiatric and psychotherapeutic outpatient services during the follow-up period.

Concordance between two personality disorder instruments with psychiatric inpatients

Eighty-two psychiatric inpatients received axis II diagnoses on the Millon Clinical Multiaxial Inventory (MCMI-1)--a self-report instrument--and the Structured Interview for DSM-III Personality (SIDP). Those two instruments were then compared in terms of personality disorder categories and trait-scores (dimensions). Essentially, with the exception of the borderline category, concordance between the two instruments was poor on all scales. Bayesian statistics confirmed the obtained results. The adequacy of the MCMI-I as an index of DSM-III personality disorders is questioned.

Diagnosing personality disorders in psychiatric inpatients

This study investigated assumptions made by DSM-III and DSM-III-R regarding Axis I-Axis II associations and sex differences for the 11 personality disorders (PD). A total of 112 patients formed 4 Axis I diagnostic groups: recent-onset schizophrenia (n = 35); recent-onset mania (n = 26); unipolar affective disorder (n = 30); and a mixed diagnostic group (n = 21). The prevalence of PD was determined using the Structured Interview for DSM-III Personality Disorders (SIDP). Schizophrenia was associated with antisocial PD and schizotypal PD; manic disorder was associated with histrionic PD; and unipolar affective disorder was associated with borderline, dependent and avoidant PD. Some of these results were consistent with DSM-III/DSM-III-R postulates. However, there was little support for the DSM-III/DSM-III-R statements on sex differences in the prevalence of PD, except for antisocial PD. The implications of the results for DSM-III/DSM-III-R assumptions are discussed.